1. Chapter 19: The Ankle and Lower Leg

4. Functional Anatomy Ankle is a stable hinge joint
Medial and lateral displacement is prevented by the malleoli
Ligament arrangement limits inversion and eversion at the subtalar joint
Square shape of talus adds to stability of the ankle
Most stable during dorsiflexion, least stable in plantar flexion

5. Degrees of motion for the ankle range from 10 degrees of dorsiflexion to 50 degrees of plantar flexion
Normal gait requires 10 degrees of dorsiflexion and 20 degrees of plantar flexion with the knee fully extended
Normal ankle function is dependent on action of the rearfoot and subtalar joint

6. Preventing Injury in the Lower Leg and Ankle
Achilles Tendon Stretching
A tight heel cord may limit dorsiflexion and may predispose athlete to ankle injury
Should routinely stretch before and after practice
Stretching should be performed with knee extended and flexed degrees
Strength Training
Static and dynamic joint stability is critical in preventing injury
While maintaining normal ROM, muscles and tendons surrounding joint must be kept strong

7. Preventive Taping and Orthoses
Footwear
Can be an important factor in reducing injury
Shoes should not be used in activities they were not made for
Preventive Taping and Orthoses
Tape can provide some prophylactic protection
However, improperly applied tape can disrupt normal biomechanical function and cause injury
Lace-up braces have even been found to be superior to taping relative to prevention

8. Assessing the Lower Leg and Ankle
History
Past history
Mechanism of injury
When does it hurt?
Type of, quality of, duration of pain?
Sounds or feelings?
How long were you disabled?
Swelling?
Previous treatments?

9. Percussion and compression tests
Used when fracture is suspected
Percussion test is a blow to the tibia, fibula or heel to create vibratory force that resonates w/in fracture causing pain
Compression test involves compression of tibia and fibula either above or below site of concern
Thompson test
Squeeze calf muscle, while foot is extended off table to test the integrity of the Achilles tendon
Positive tests results in no movement in the foot
Homan’s test
Test for deep vein thrombophlebitis
With knee extended and foot off table, ankle is moved into dorsiflexion
Pain in calf is a positive sign and should be referred

10. Compression Test
Percussion Test
Homan’s Test
Thompson Test

11. Ankle Stability Tests Anterior drawer test Talar tilt test
Used to determine damage to anterior talofibular ligament primarily and other lateral ligament secondarily
A positive test occurs when foot slides forward and/or makes a clunking sound as it reaches the end point
Talar tilt test
Performed to determine extent of inversion or eversion injuries
With foot at 90 degrees calcaneus is inverted and excessive motion indicates injury to calcaneofibular ligament and possibly the anterior and posterior talofibular ligaments
If the calcaneus is everted, the deltoid ligament is tested

12. Anterior Drawer Test
Talar Tilt Test

13. Functional Tests
While weight bearing the following should be performed
Walk on toes (plantar flexion)
Walk on heels (dorsiflexion)
Walk on lateral borders of feet (inversion)
Walk on medial borders of feet (eversion)
Hops on injured ankle
Passive, active and resistive movements should be manually applied to determine joint integrity and muscle function
If any of these are painful they should be avoided

14. Specific Injuries Ankle Injuries: Sprains Inversion Sprains
Single most common injury in athletics caused by sudden inversion or eversion moments
Inversion Sprains
Most common and result in injury to the lateral ligaments
Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation
Occasionally the force is great enough for an avulsion fracture to occur w/ the lateral malleolus

15. Syndesmotic Sprain Etiology Signs and Symptoms Management
Injury to the distal tibiofemoral joint (anterior/posterior tibiofibular ligament)
Torn w/ increased external rotation or dorsiflexion
Injured in conjunction w/ medial and lateral ligaments
Signs and Symptoms
Severe pain, loss of function; passive external rotation and dorsiflexion cause pain
Pain is usually anterolaterally located
Management
Difficult to treat and may requires months of treatment
Same course of treatment as other sprains, however, immobilization and total rehab may be longer

16. Achilles Tendon Rupture
Etiology
Occurs w/ sudden stop and go; forceful plantar flexion w/ knee moving into full extension
Commonly seen in athletes > 30 years old
Generally has history of chronic inflammation
Signs and Symptoms
Sudden snap (kick in the leg) w/ immediate pain which rapidly subsides
Point tenderness, swelling, discoloration; decreased ROM
Obvious indentation and positive Thompson test
Occurs 2-6 cm proximal the calcaneal insertion

18. Achilles Tendon Rupture (continued)
Management
Usual management involves surgical repair for serious injuries (return of 75-80% of function)
Non-operative treatment consists of RICE, NSAID’s, analgesics, and a non-weight bearing cast for 6 weeks, followed up by a walking cast for 2 weeks (75-90% return to normal function)
Rehabilitation lasts about 6 months and consists of ROM, PRE and wearing a 2cm heel lift in both shoes

19. Medial Tibial Stress Syndrome (Shin Splints)
Etiology
Pain in anterior portion of shin
Catch all for stress fractures, muscle strains, chronic anterior compartment syndrome
Accounts for 10-15% of all running injuries, 60% of leg pain in athletes
Caused by repetitive microtrauma
Weak muscles, improper footwear, training errors, varus foot, tight heel cord, hypermobile or pronated feet and even forefoot supination can contribute to MTSS
May also involve, stress fractures or exertional compartment syndrome

20. Shin Splints (continued)
Signs and Symptoms
Four grades of pain
Pain after activity
Pain before and after activity and not affecting performance
Pain before, during and after activity, affecting performance
Pain so severe, performance is impossible
Management
Physician referral for X-rays and bone scan
Activity modification
Correction of abnormal biomechanics
Ice massage to reduce pain and inflammation
Flexibility program for gastroc-soleus complex
Arch taping and or orthotics

21. Compartment Syndrome Etiology Signs and Symptoms
Rare acute traumatic syndrome due to direct blow or excessive exercise
Signs and Symptoms
Excessive swelling compresses muscles, blood supply and nerves
Increase in fluid accumulation could lead to permanent disability
Chronic cases appear as gradual build-up that dissipates following activity; generally bilateral and becomes predictable; can remain elevated producing ischemia and pain or ache w/ rare neurological involvement; increased pressure involvement
Weakness with foot and toe extension and occasionally numbness in dorsal region of foot

22. Compartment Syndrome (continued)
Management
If severe acute or chronic case, may present as medical emergency that requires surgery to reduce pressure or release fascia
RICE, NSAID’s and analgesics as needed
Surgical release is generally used in recurrent conditions
Return to activity after surgery - light activity- 10 days later

23. Functional Progressions
Severe injuries require more detailed plan
Introduction of weight bearing activities (partial vs. full) is critical to progress
Progression must occur based on pain and level of function
Running can begin when ambulation is pain free (transition from pool  even surface  changes of speed and direction)

24. Return to Activity
Must have complete range of motion and at least 80-90% of pre-injury strength before return to sport
If full practice is tolerated w/out insult, athlete can return to competition
Return to activity must involve gradual progression of functional activities, slowly increasing stress on injured structure
Specific sports dictate specific drills